The future of fertility

Thirty years ago the birth of Louise Brown, the world's first test-tube baby, marked a genuine medical breakthrough – one of the few that deserves the title. Until then, the limited treatments on offer – surgery and hormone therapy – could help only some of the millions of infertile couples devastated by the discovery that they were unable to create a family.

On 25 July 1978 they learnt they had another option that could deliver a baby – and a future. Early fears about the safety and morality of the procedure were swept aside in the rush to take advantage of it. Today, some four million babies have been born by IVF worldwide. In Britain it is estimated that every primary school has at least one IVF child.

Yet as quickly as it has solved problems, the new science of fertility has created them. No area of medicine has seen more spectacular advances, but no area has thrown up more ethical conundrums.

At the time of Louise Brown's birth, doctors were able to treat barely half of the infertile couples – one in seven of the population – who came to them for help. Surgery for blocked fallopian tubes and hormone treatment to stimulate egg production were the only available treatments for women. There was nothing available for men.

Today, in a special report published by the journal Nature, scientists make some extraordinary predictions about the future of fertility treatment. They forecast an end to infertility with the potential for any person of any age from one to 100 to have children. In place of a normal pregnancy, gestation might take place in an artificial womb, with embryos selected and genetically manipulated to ensure they were free of disease.

Low-cost IVF might be made available at £50 a cycle, putting it in reach of some parts of the developing world. Cloned babies, though banned in this country and many others, are likely to become a reality, scientists say.

Thirty years ago these claims would have been treated as science fiction. Today they seem entirely realistic, beside the advances we have already seen. Who would have predicted in 1978 that male infertility would be successfully treated by injecting individual sperm directly into the egg? The technique, known as intra cytoplasmic sperm injection (ICSI), first introduced in 1992, is now used in more than half of all IVF treatments in the UK.

Who would have predicted that embryos would be selected, by sex or by genetic markers for almost 200 diseases using the technique of pre-implantation diagnosis, so that only healthy ones were replaced in the womb?

Today we have saviour siblings (babies created to provide a sick older sibling with matching tissue) and animal-human hybrids (created by placing human cell nuclei into the eggs of cows or rabbits to create embryos that are 99 per cent human and are used for research up to 14 days – because of the shortage of human eggs).

The most exciting area is stem-cell research using embryos – and ordinary adult skin cells treated to behave like embryonic stem cells, called induced pluripotent stem cells (iPS) – from which it is hoped new tissue can be grown for the treatment of conditions including Alzheimer's , Parkinson's and similar conditions.

This is the new scientific frontier on which, 30 years on from Louise Brown's birth, researchers now stand. Work on embryos which was exclusively focused on developing new treatments for infertility has now expanded to include the search for cures for disease. With an updated Bill due to be passed into law later this year, which gives legal sanction to these techniques, the stage is set for further advance – and further controversy.

See www.nature.com

Looking ahead: how the news may be made

100-year-old gives birth

Davor Solter, a developmental biologist at the Institute of Medical Biology in Singapore

I think IVF has gone about as far as it can. Next I expect that germ cells – sperm and eggs – will be derived from induced pluripotent stem (iPS) cells [cells that have the potential to develop into any of the body's cell types]. It will be possible to make iPS cells from skin cells, to make germ cells from these, and then combine them to make human embryos. It means every person, regardless of age, will be able to have children: newborn children could have children and 100-year-olds could have children. It could easily happen in the next 30 years. I have no idea if the technique will be used, but it means you could have millions of gametes that could be combined at will. I have no idea what kind of moral value or rights we would give to those embryos. We'll probably go through the same agonising we did with IVF. It could be terrible to begin with, but then it'll become a fact of life. Maybe 20 to 30 years from now we'll read that someone made 20,000 embryos and studied their development, and we'll decide it's OK.

Cost of IVF falls to £50

Alan Trounson, an IVF pioneer and director of the California Institute for Regenerative Medicine in San Francisco

IVF was a gigantic step. We didn't realise it at the time; people didn't think it would work that well. We never envisaged that it would expand so dramatically around the world. Ethics keeps moving. What was once seen as dangerous goes on to be seen as within the confines of acceptable risk. Probably the major development in the field will come from something we've never thought about. I think there will be a further expansion of low-cost IVF, especially for women in developing countries who experience social discrimination with infertility. If you remove all the expensive stuff and use low-cost drugs (such as clomiphene) and remove just one or two eggs, and only transfer one embryo, it can be done for less than US$100 (£50).

First cloned baby born

Miodrag Stojkovic, stem-cell biologist at the Prince Philip Centre of Investigation in Valencia, Spain

Will we see a cloned baby? It could happen any day because of a lack of regulation [in some countries]. People are already trying to do reproductive cloning. The only problem is getting hold of enough viable human oocytes [eggs]. If we can make human oocytes from stem cells, it might be easier. There is no medical need to clone a human. The future is not about reproductive cloning, that's a very, very detrimental technique.

The artificial womb

Scott Gelfand, director of the Ethics Centre at Oklahoma State University in Stillwater

There is some research aiming to increase embryo survival. There are also people who are working on the other end – at the moment babies can only survive from about 22 weeks. Someone could join these two advances together and we could have complete ectogenesis [in which the foetus develops outside the body in an artificial uterus]. I find it interesting – and scary. Even in terms of insurance: if it became economically competitive with other forms of gestation, insurers might compel a person to use it to avoid premature birth or foetal alcohol syndrome. It's something that really needs to be talked about. Will it happen? Dolly was a complete surprise to everybody...

Parents can choose favourite embryo

Susannah Baruch, director of reproductive genetics at the Genetics and Public Policy Centre at Johns Hopkins University in Washington DC

There's speculation that people will have designer babies, but I don't think the data is there to support that. No single gene predicts blondness or thinness or height or whatever the 'perfect baby' looks like. You might find genetic contributors, but there are so many environmental factors too. More likely is that you'll have a set of embryos and you'll know every single thing about every gene in every embryo. For example, one embryo will have three genes associated with tallness, two for weakness, three for poor vision and some for disease; and the second embryo will have some other set. None of us is a perfect specimen and none of our embryos will be, either. I think you'll end up with a lot of information but it's less obvious how useful that information will be and how many parents will want it. Will people choose IVF to get that genetic option? The old-fashioned way is cheaper and more fun and that won't change in 30 years.

Infertility is history

Zev Rosenwaks, director of the Centre for Reproductive Medicine and Infertility in New York

I see the technology going towards possible eradication of infertility altogether. With nuclear-transfer technology or cell modification, I think we'll be able to generate sperm and eggs for anybody.